Dr. Andy

Saturday, February 26, 2005

Come Do Some Time with Us

So goes an advertisement for medical professionals to work for a company specializing in prison health care, according to a disturbing story in the New York Times

As the story points out, who the hell is going to work as a doctor or nurse in a prison. The pay, I assume, is probably crappy, the prestige negative and the population about the worst you could imagine, even neglecting the high prevalence of borderline personality disorder (think sociopath).

Except for the odd deeply religious individual who sees prison work as his ministry, the medical profesisonals these companies recruit are likely to be the bottom of the barrel.

Nonetheless, the examples of care provided in this article are horrendous. Of course, prisoners probably don't make very good plaintiffs in malpractice suits, so the companies can get by with substandard care and not give too much back in malpractice.

Friday, February 25, 2005

Oops

My sense is that this kind of thing, albeit less extreme, happens a lot. Once a patient carries a diagnosis it is hard to break out of thinking in them as "The patient with X" and consider that maybe they have something else entirely (or nothing at all).

Elidel and Protopic Linked to Cancer

The FDA reports that Pimecrolimus (Elidel) and Tacrolimus (Protopic) are linked with development of skin cancers and lymphoma. Oops. As a pediatric allergist/immunologist who has prescribed both of these a fair amount this makes me a bit scared. I've also used them off label for kids <2, although apparently no cancers have been seen in this age group.

Both medicines act by inhibiting T cells and when used systemically Tacrolimus predisposes to lymphoma, so the mechanism is plausible.

Of course, both medicines, and Elidel in particular were heavily marketed as "steroid free" since parents are so steroid-phobic. I sometimes explain to parents "these medicines are powerful immunosuppressants originally designed for organ transplant recipients. Some cowboy decided to make a cream out of them and put them on the skin of kids with atopic dermatitis. Now do you feel better that you aren't using steroids, which have been used for years with minimal side effects when used correctly?"

The overall risk is quite low. According to the link, there were nearly 5 million combined prescriptions in a year and maybe 27 total malignancies over several years. Of course, this is a passive reporting system, so it underestimates risk.

Mason & Dixon

Just finished Mason & Dixon, Thomas Pynchon's novel about the famous astronomer and surveyor, respectively, who put measured out the border between northern and southern states that bears their name (eponymous is the word -ed.). A great book

With Pynchon, I always feel there are a million details and plot twists I don't quite understand. I used the companion when I read Gravity's Rainbow which helped a lot. Anyway, in my non-expert view, Mason & Dixon boils down to the story of a great friendship between the two, with the usual crazy Pynchon antics thrown in. Like many male friendships, they are never quite able to break through their customary reserve and express their feelings, but it is a touching story none the less.

I hope to read this again, as I think I'd pick up a lot more the second time. I'd also try to read some more about it beforehand (criticism on the web, amazon reviews, etc).

Thursday, February 24, 2005

Costs Keep Going Up

Health care costs will continue to outpace the overall rate of inflation, and the government share of the overall bill will increase. I am not an economist or a particular expert in health care economics, but I'll venture a few thoughts:

1. That the U.S. is spending an increasing fraction of GDP on health care does not concern me. What else should we spend it on? More Ipods? We are a wealthy society and medical care seems a reasonable thing for a wealthy society to spend its money on.

2. It will be very hard to restrain healthcare costs as long as everyone thinks they are entitled to the same level of healthcare that the rich can afford. Think about it: a reasonable goal for society is that noone is without food or shelther, but no one (alright, few) would argue that everyone should have the same quality of food or shelter that the wealthiest members of society can afford. Instituting some basic cost-effective health care for everyone and making the rest available only for those who can afford it would go a long way toward reducing overall costs.

3. As long as people see medical care as a free good, costs will continue to go up. Health savings accounts (HSAs) MIGHT be able to bring down costs because consumers will actually have an incentive to seek out better prices. I still worry that the amount of information available about quality (and the difficulty of gathering such data) will be an impediment.

4. As the federal governments share of health care costs, pushing through a single-payer system, although it seems improbable currently, will get easier.

Wednesday, February 23, 2005

Bedside Rationing

A fascinating post about the role of clinicians in "bedside rationing" of medical care at Maurice Bernstein's blog, Bioethics Discussion. As I understand it (and I am not an ethicist) bedside rationing means individual docs deciding what care to provide to their patients based on what is cost effective.

In general, doctors are taught that there responsibility is to their individual patients. Therefore, we should do whatever is best for our patient, and not consider, for example, that exorbitant spending will drive up the cost of health care, making it less available and affordable. How costs are controlled is left a bit blurry, but usually it is felt that insurance companies or HMOs will ration care by refusing to pay for certain treatments or at least putting limits on when they'll pay.

I'd like to describe a specific example. Omalizumab (trade name Xolair) is a recently approved treatment for patients with asthma. IgE is the antibody that causes allergies. When you have IgE to something you have reactions like hives, wheezing, etc when you are exposed to that specific thing (technical term is antigen). If you are allergic to peanut, you have IgE that recognizes peanut and when you eat peanut you will get hives, throat tightness, difficulty breathing, etc (anaphylaxis). Reactions to antigens that are found in the environment are generally less severe and triggered by inhaling the offending agent. Examples would be cat dander and ragweed pollen and symptoms might be runny nose and congestion (allergic rhinitis) or wheezing and difficulty breathing (asthma).

Omalizumab is an antibody (an IgG antibody, a different type than IgE) that recognizes human IgE. The idea is that it binds up the IgE you already have and prevents the IgE from causing an allergic reaction. It is now approved in use for patients with moderate to severe persistent asthma (this is per national guidelines and represents pretty hard to control asthma; to the layman moderate persistent asthma would seem severe) who meet certain criteria regarding IgE level and having demostrated allergies. It works, with pretty dramatic reductions in severe exacerbations, ED visits and hospitalizations. It is given as a shot every 2-4 weeks.

The problem is it is incredibly expensive (10-12,000 dollars/year and benefit probably last only as long as you keep taking it) and not cost effective (see Oba and Salzman, J Allergy Clin Immuno 04 114:265). The Oba paper suggests it would be only cost effective in patients who were hospitalized 5 or more times per year or for a total of 20 or more days. While there might be a few such patients out there, no one can identify a group of such patients prospectively.

So what am I, as a practicing allergist to do about using this effective, but expensive medicine?

It would seem I have several options:

1. Not use it at all as it is not cost-effective. It is my job to provide cost-effective care, thereby keeping overall health care costs down, making health insurance as affordable as possible, etc.

2. Use it for my most severe asthmatics, only after trying everything else (other, cheaper medicines, checking on compliance, etc). This is the in-between option. One obvious weakness is that every asthma specialist is likely to have a different approach to who to use it for

3. Use it for everyone who qualifies (there are moderately strict criteria for use, although insurance companies appear to be approving it for more people who don't quite meet the criteria). It is not my job to ration health care. I will do what is best for my patient and it is for someone else to figure out how to make health care more cost effective

I would say I'm between 2 and 3 in my use. I don't give it to just everyone, but I do use it for pateints with pretty bad asthma who aren't responding to other medicines or who have a decreased quality of life, even if they are rarely if ever so sick they need to go to the ED or be hospitalized. In general, I wouldn't prescribe it for those who won't be compliant with inhaled steroids and other less expensive medicines.

Two more scenarios1. A young woman (say 22) with severe asthma, known cat allergy who refuses to give up her multiple cats and even sleeps with a new kitten here fiancee gave her (must really love her a lot, huh)2. A similar women with severe asthma who is a smoker.

I said no to #1, but yes to #2. Why? I can't justify it. The women in #1 seemed obnoxious to not even consider trying to get rid of the cats, while the women in #2 wanted to quit smoking (and we are working on this) but was just so addicted. I told a colleague about this, and she was outraged. She felt patient #1 was justified in not wanting to give up her beloved cats, while patient #2 had no particular reason to keep smoking.

I think these two cases illustrate the difficulties in each provider acting to ration care. Based on differences between providers (not surprisingly my outraged colleague is an animal lover and I am not) you will get very different outcomes.

My overall belief is that leaving docs to do what is in their patients interest and someone or something else to ration care is best, but I can't tell you who or what that other entitiy is.

Stem Cells

An interesting article in the New York Times today about stem cells and Hans Keirstead one of the stem cell researchers behind the proposition recently passed in California to fund stem cell research.

Hans S. Keirstead might be the Pied Piper of stem cells - and not just because he makes rats walk. He also helped lure Californians to the polls last fall to approve spending $3 billion of the state's money on embryonic stem cell research over the next decade. But he has critics who worry that he may be leading their new field too far, too soon into uncharted territory

Sounds like he has fascinating, but preliminary data using stem cells to help mice with nerve injuries. Stem cells are differentiated into oligodendrocytes, a type of cell that is found in brain and nerve tissue where it acts to help "support," for lack of a better word, the actual neurons or nerve cells. The article doesn't make clear how the mice were injured, so it is hard to know how applicable this model might be to human spinal cord injuries.

It does seem a bit suspicious that he has been showing a video of a mice that can walk after treatment for three years, but hasn't got around to publishing the results. Maybe he doesn't want to disclose how he differentiates the oligodendrocytes, but that would go against the general drift of his supporters that he only cares about patients, not himself.

In general my belief is that the decision to move into clinical trials should weigh risks and benefits. In the case of spinal cord injury, it would seem the possible benefits of treatment would far outweigh any risks. On the other hand, it also seems that animal data should be published and replicated by other groups before moving on to human studies.